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11/02/2610 21:25 7634975011 SPTESTINGINC PAGE 03/09
<br /> ; Minr�esc�ta aollu�tion Connpl�a�n�e Inspec,fil01'1 FI�I"�11
<br /> f� , � .
<br /> `..;r,�: Ccmtrol �,c�ency
<br /> ExA$ting Subsurface Sewa�ge Tr�atme�tt Systertns �SS�'9)
<br /> 5�0 Lafayehe R�ad Nertl,
<br /> St.Paul,MN 55155•41gq doc rype:Compllenca end Cntoitiement
<br /> It�strucf;ions on page G
<br /> Su�'1111�117/ F'Oi'�'Y1 (Compleled form must be submitked to the local unit oi govemm�nt within 15 days,)
<br /> Par�el number:
<br /> Syslem staius: �Compliant 1� Noncompliant For�ocal 7racking Purpos�s; -�-- '----��
<br /> (hAsed on all co►npl�ance requiromenls)
<br /> Prope�rt,� Informati�on ..` .. . --�"—_ .—.. _—.�. -
<br /> I�roperty owner name(s): ��M� a ����,���_��� � ��o�eKy o�nmer phone: �SZ-k0
<br /> Property eddress: •�''�S�^�
<br /> �-s,_L���'C'����v'�G
<br /> —�►��a�_...�U�O
<br /> f'roperty owner address(Ir df�erent): " "� � �— •—• �
<br /> . _.,. __ .., ... .,, _..,_
<br /> -,...._ _., _
<br /> -—
<br /> ouniy: . �,� ,�,,�---,, Permitiing Aulhorily: rG��(�{
<br /> ..,_ r .1..1,�_,._
<br /> Date s sl;em constrt.ioted: �— ��� �---•�--..-
<br /> Y _ I 9`,�,� Roaeon For inspeGtion;_����::_l.�L���_ .—_.
<br /> System Descr�p��ora �
<br /> B�ief system descripkion: a.-1�v�Q�f _5'�•�1��(l�;bf,��1_0��° a�?�w�.�.L�-1-Q��1�b,,,r, , �.dW i�o-_..lv�5o,�a r���.
<br /> Y�n�. �.
<br /> Looal permiC numher: _ __ Number of hndrooms; (�esign 11ow rate:
<br /> `f.— _._.(ov_Co.__:---
<br /> Is thm system: .
<br /> In Shorelan,d area7 ❑Yea � No In Wellhead Prolection A�ea? ❑ Yos � No
<br /> An U.S.�nvironmenlal Protection System servfng a Mlnnesola Deparlmont
<br /> Agency(�PA) Class 1/Injection Well7�Yes � No uf Heath(MDH)licensed facilily7 �]Yes �No
<br /> CO(11plienCe St3tU5 (B�sBd on stele�quiremenfs-��lditlonalloc�l r+equ;rements may elso apply,)
<br /> Based on th� iniormatinn gathered�nd reported on altached forms, the complfance status of this system is(checic one):
<br /> � Certificate of Compllancp�valfd until (3 years lrom date of rt�port):
<br /> ❑ Notice of Noncompll�nce-�or Noncompliant eyatems: ��� �" " '
<br /> The roason For noncompNanca is:
<br /> . ..,.,_ ,..- ---,.. .
<br /> This noncompliank syst�m is classiFad as (check one below): �� � '-- "-
<br /> ❑ Imrnlnent Ihreat ko publfc health 8�s�fety ❑ Failing to protect grouncl wate� �]Not in compliance with operating permil
<br /> Cerfiificr�t�on
<br /> I her+eby c�rtirjr thal all th�necessery infer�nation has Gc��n gathered lo clefermino the complianr.v sfetus of ihis sysiem_ No
<br /> determination of(uf�ire sysM�n perl'ormance has been norcan be made due to unl�nown concllfions during qystem construction,
<br /> possible abuso of the syst�m, Il1�1(JQ(�(IA�I77S/AIBl17f7¢Q, or fufuro wete►'usage_
<br /> Namo; ������L�G.���1,,•��,/'�ca Certifioaiion number: ''
<br /> �2c`�..,,,)
<br /> Bi,islness Ilcense namo and nwnber: ..5-{i '� �SrS�.1),-�\���._,...,..�-L��•�.w_�`����I.µ�_7 d � ° ` "'..y�l�zl�? or
<br /> -� !�J�J..-• 9
<br /> Name of local uni o�f gr�.vernment:
<br /> � �
<br /> ,._,. _,.,... ,-- --�,,......---
<br /> —_.... ..�
<br /> Signature: •--. .__ � � '=_ __ ��_....-.—.- .... Oate: ��_,�v..`�U_,__,------
<br /> Require�d ,�ttachme�ts
<br /> Hydraulic f'erformance �Tank Integrity ❑ Operaling Permit Fo�m (if applicable)
<br /> Soil 13oring l,ogs � Soil Separation
<br /> Systerri d�awing/ns-built drawing [J Any local requlrements lhat are diFferent from what is required on this form
<br /> ❑Olher inFormt�tlon (list)'
<br /> replac�d,ori�s use dlsconffnued w --- ..' --. —.�� ___.`
<br /> Upgrade Requireme�ltg (derivr�d frpm Mlnn. St�tt. § 9 95.55)/.►n lmminent lhrP�f fo publ/c health and sel�e(y(ITl�HS)mus�be upgraded,
<br /> • !thln ten months ol receipt of thls nof,lce or wlthln a sl�orfer perlod!(►pquired by/ocel o►Ylinanco./!tne sysfem fs
<br /> falOng to protect ground w�ta,r, thQ system musf be up.qraded, roplaead,vrlts us9 diseontln�aed wfthin Fhg t/nt6 roqulred b�i lor,�l orc/lnence, If en
<br /> exisfing syst�m Is not falling as definad!n lew, And/ios o(laast two feet ol daslqn coll ssparel/on, then the system nee,d not Ge upgradad,repe/red,
<br /> r+ep/Aced, orlts use dlsconflnuod,notwRhstnnding an�i locel ortilnenco f/�al!s mo►a strlct. 77�Is p►�vislon�foes not appty to aystr�ms!n shor�/�nd
<br /> arnas, WellheArJ Protecllon Areas,or flioso ussd in connectlon wlflr fond, bev�rege,and lodping estehlishmonts as dAfin�rA in law.
<br /> �-----•. ..--._._._,..--- -,..... _...,, ._,,,
<br /> www.pca.sk�te.mn.us • 651-296-6300 • 800-657-3864 • TTY 651-Z8),-5332 or 800-657-3864� • Avallable in allem9tive formals
<br /> wq-wwlsL�s�1•3f � 4/2d/09
<br /> Pnon'i nf A.
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